Bringing Care to the Kids: Health Hub School-Based Clinics a 20-Year Success Story

Newton School fifth-grader Erik Younce gives pediatric nurse practitioner Frank Lamson a dose of his own medicine after Lamson had done a check on Younce. Lamson was at the school in Strafford, Vt., on April 29, 2014. (Valley News - Jennifer Hauck) Purchase photo reprints »

Amanda Lyman, a junior at the South Royalton School in South Royalton, Vt., has her teeth cleaned by Health Hub's dental hygienist Merry Muller on April 29, 2014. The dental trailer is parked at the school when seeing students. (Valley News - Jennifer Hauck) Purchase photo reprints »

As students return to their classroom at left, pediatric nurse practitioner Frank Lamson and school nurse and clinic coordinator Ellen Gnaedinger chat with a student at the Newton School in Strafford, Vt., on April 29, 2014. (Valley News - Jennifer Hauck) Purchase photo reprints »

Health Hub nurse practitioner Frank Lamson leaves the Newton School clinic in Strafford, Vt., to go to the South Royalton School clinic in South Royalton, Vt. on April 29, 2014. (Valley News - Jennifer Hauck) Purchase photo reprints »

At the clinic in South Royalton, Vt., on April 29, 2014, South Royalton sophmore Jake Kinnarney talks with nurse practitioner Frank Lamson about his back that he hurt playing basketball. Jake's mother Gloria works at the school and had asked Lamson if he could check in with Jake. (Valley News - Jennifer Hauck) Purchase photo reprints »

South Royalton — A weekly checkup for asthma found 11-year-old Erik Younce laughing with Frank Lamson, the pediatric nurse practitioner with Health Hub and the Strafford School-Based Health Clinic, a group of school-based clinics in the Orange Windsor Supervisory Union.

“Frank’s one of his favorite people,” said Erik’s mother, Kumari Patricia Younce.

Erik, a Newton School student, also sees Lamson at South Royalton Health Center, “but it’s really good to have (the clinic) at the school,” she said. “I’m a single mom and I work, and it’s hard to get the kids there when they are sick.”

The trip from their Strafford home to the health center takes about 25 minutes, and during the winter and mud season, “you have to pick the right roads,” said Younce, a professor at Goddard College in Plainfield, Vt. “This is much, much easier.”

That accessibility is an important part of what organizershad in mind when they created the first of several school-based clinics 20 years ago.

“In a way, it’s like making house calls at the schools,” said Lamson, who founded the program with Dr. Becky Foulk, a pediatrician who is Health Hub’s medical director .

The first Health Hub, which was also the state’s first school-based clinic, started 20 years ago in South Royalton School. It was part of a national push by the Robert Wood Johnson Foundation to encourage the development of school-based health clinics. Vermont wanted to establish a rural health clinic, and Foulk and Lamson applied for the three-year grant, with the help of a team that included school employees, students and other community members.

A number of factors prompted the effort. At that time, the South Royalton Health Center stayed open two nights a week and some Saturdays to improve accessibility for patients, said Lamson, 65, who has worked with Foulk at the health center for more than two decades. Even so, for people in rural areas lacking reliable transportation, access was “certainly an issue.”

The community was concerned about the large number of teen pregnancies in the school and wanted to teach students about the responsibilities of parenting, said Foulk, 63. Then, she heard a friend describing her role as a school physician in Burlington and “sort of got grabbed by the thought of bringing care to where kids are.”

In addition, they hoped to provide mental health services, said Lamson, who had worked in a school-based clinic during his nurse practitioner training.

After the clinic opened, word spread. Foulk traveled to local schools, talking with principals. Soon, clinics were added in the supervisory union’s other schools. They now hold regular hours two days a week in South Royalton; one day a week in Chelsea, Tunbridge and South Strafford; and provide services in Sharon as needed. If necessary, Lamson visits the schools on additional days.

For a time, the health center and the clinics in the South Royalton and South Strafford schools were associated with Gifford Medical Center. Now all of the Health Hubs and the Strafford School-Based Health Clinic, part of the same nonprofit, operate in collaboration with the South Royalton Health Center, which is owned by Foulk. Most patients are school-age, but occasionally a parent brings in a younger child and “asks one of us to take a look,” Foulk said.

They offered medical and mental health care first, and recently added dental services. Students can be seen during the school day for everything from sports physicals to flu shots, by appointment or as walk-ins.

“The goal is to try and keep kids in school as much as possible and to maximize their learning potential by keeping them healthy,” Foulk said.

Richard Talbot, principal of Tunbridge Central School, said that’s been the case. “If these kids have issues, they aren’t in the class. Their brains are other places,” Talbot said. “When they are healthy, they are ready to learn. … Who among us isn’t that way?”

Health Care Pioneers

Foulk and her group have been pioneers in developing community-based systems of care that deliver excellent preventive services, said Dr. Steve Chapman, director of the Boyle Community Pediatrics Program and associate director of child health at the Center for Primary Care and Population Health at Dartmouth-Hitchcock Medical Center. “I think we need to see more of it.”

Chapman sees their work as part of a regional effort to create a system of care that includes community partnerships, along with modes such as telehealth and e-visits, to enable providers to give better, more accessible and less costly care.

His colleague, Dr. Ethan Berke, who previously worked with an organization that had a school-based clinic, agrees.

“If we are really trying to take care of the population and the community and families, we need to do a better job in medicine of delivering the care on the patients’ terms, wherever they are, and whatever the mode that is best for them,” said Berke,Dartmouth-Hitchcock’s director of primary care in the Lebanon region.

The clinic at South Royalton School was “good for everybody,” said Shaun Pickett, who retired in 2012 after 26 years as the school’s principal. “I never kept any stats, but I think it probably improved attendance.”

It’s especially helpful for students who needed to see a doctor, but whose parents found it difficult to take off time from work, said Pickett, who served on the committee that wrote the original grant. “Some parents, if they’re not at work, they don’t get paid.”

Tracy Vesper, administrative assistant at the Tunbridge school, said Health Hub saved her taking off entire days to drive her now adult son, Benjamin, to his primary care physician in Lebanon. Like many students, Benjamin was in elementary school when he started seeing Lamson, who got to know “all the ins and outs of him.”

“The students really trust him,” Vesper said. “If you think about all those things, having it so local, you can’t ask for anything better.”

‘On Their Own Turf’

On a recent afternoon, Lamson walked through the halls of South Royalton School, where he and students greeted one another by name, sometimes sharing a fist bump. Hesees sick and injured children, those with chronic medical conditions, and provides preventive care, such as annual physicals and immunizations. Many students receive their primary care through the clinics.

School nurses who encounter problems beyond their scope of practice can refer students to Lamson. For example, he might run a strep test on a child with a “really hot-looking sore throat” and call in a prescription if necessary, he said. And he usually has medication on hand so sick students “can get started right away.”

From September to March, Lamson had 392 visits, about 100 each in Chelsea, Tunbridge, South Royalton and South Strafford, said Ellen Gnaedinger, the school nurse and clinic coordinator at Newton School.

Of about 120 students at the school, roughly 60 percent are signed up to receive medical services, she said. Between medical and dental care, “there are very few kids that aren’t seen by some part of the school clinic.”

Girls who prefer to see a female doctor can be seen by Foulk.

“It’s her morning off, and she’s coming over to do well-child checks for those adolescent girls,” Gnaedinger said. “It’s a labor of love.”

For Lamson, the most important aspect of Health Hub is the chance to see kids “on their own turf” and the built-in ability to follow up. In an office setting, when a patient requires a follow-up visit, “you make an appointment and hope they come in,” he said. But a family’s ability to follow through is affected by “all kinds of contingencies,” including lousy cars, career changes or even the fear of losing a job.

He’s also able to coordinate with teachers, guidance counselors and therapists. “The more facets that you get to know of these kids, the more you can really address their needs both as a medical provider and a teacher,” he said.

On a recent morning, he and Phil Diamond, who manages Tunbridge Central School’s after-school program, stopped in the hallway to touch base about a student. The boy, whose parents were unable to provide after-school supervision, had struggled with his homework and “desperately needed” to be in the program, Lamson said. But his behavioral issues made it impossible. Lamson started him on a medication and adjusted it, based on “lots of feedback” from the student and his teachers. The boy, who recently began attending the program, is doing really well, Lamson said.

Pregnancy, Obesity And Opiates

From reflex hammers to a blood pressure cuff to an ophthalmoscope, the contents of Lamson’s black doctor bag haven’t changed much over the decades. But the health issues he and his colleagues encounter have.

Current concerns include nutrition, the obesity epidemic and opiate abuse, “which has really mushroomed in the last five years,” Foulk said. Addressing those issues is “a work in progress,” and providers are always talking about what proven, evidence-based curriculum they might implement in the school setting.

Childhood obesity rates in Vermont are lower than some places in the country and higher than others, Foulk said. “We’re not quite as bad as Mississippi, but it also tends to go hand in hand with poverty rates. … This is a poorer part of the state, and often that results in poor nutrition.”

Physical education programs, a focus on good nutrition, and the availability of competitive and noncompetitive athletic activities at the schools have helped keep students healthy, Lamson said, and the clinic staff also promote good eating habits and physical activity. “You know exercise is good for you,” he often says to students. “How are you going to get some?”

Recently, thanks to a variety of organizations, they have seen “some big changes,” such as healthier school lunches, Foulk said. “We’re always trying to partner with community organizations and not duplicate efforts.”

When it comes to addiction, the mental health counselors do “quite a bit of work” with children who are addicted and those whose family members struggle with addiction, Lamson said. Being at the school gives him a window on what’s happening throughout the community. When addiction is suspected in a family, he specifies that prescription drugs with street value be administered during the school day. That way, “you know the kid gets his medication on time every day, and it can be accounted for.”

At the same time, certain health concerns have subsided. Although the United States still trails the rest of the industrialized world, the rates of teen pregnancy have fallen locally, as they have across the country, Lamson said. Also, communication about difficult issues seems to be improving, with problems such as pregnancy and drug abuse much more readily acknowledged than they were decades ago.

The HPV vaccine and contraceptives are available through the clinics, and if students are over 14, the state generally considers them old enough to consent to confidential treatment for family planning, sexually transmitted diseases and drug addiction, he said. “In the real world, those obviously are big issues that should be a subject of family communication.”

When the clinics first started, the question of how they would handle those situations came up often, but since then, it has not been an issue, he said. Sign-up materials for the clinics specify that those services are offered, and parents with strong objections could either opt not to sign up or send the form back with that section deleted, but it hasn’t happened.

While his primary focus is patients’ health and safety, Lamson encourages kids to talk with their parents, offering to schedule or mediate appointments that include them.

“I like to take that opportunity not just to teach kids about anatomy and physiology, but also about communication. When you have a problem like that, you seek out adults that you trust and you talk with them about it,” he said. “As scared as kids get in situations like that, most often their parents are very willing to talk with them about it and are happy that their kids would try to communicate with them.”

Mental Health: ‘Just Getting Through the Day’

On a recent afternoon, Lamson checked in with a student who had just moved in with a parent who has a substance abuse problem. They spent a few minutes in the nurse’s office, talking about the new living situation.

“You look kind of tired,” Lamson said.

“A little bit,” the boy said. “I went to bed at 11.”

“Try to get to bed a little earlier tonight,” Lamson told him.

“Any worries? Anything I can help you with?” he asked.

“No.”

They chatted about the allure of video games and parents’ fondness for setting rules around them. Before the student returned to class, Lamson asked if he was still meeting with a counselor. He was.

“We have always felt that mental health was an important part of school-based health clinics,” Lamson said later.

Lamson, who makes some house calls, sees aspects of rural poverty that may be hidden but have an important effect on children’s moods.

“Do they live in a place where they can bring their friends safely or comfortably, or are they ashamed of what it looks like? Is there a way to have clothes that are washed once in a while?” he said.

“You can be pretty surprised at the conditions under which people are living. … For so many kids, just getting through the day is a major accomplishment.”

Counselors employed through the clinics see children in crisis and those who require regular appointments. They also help develop individualized education programs and accommodations for special education students.

While school guidance counselors also provide counseling, they really like having additional resources, Lamson said.

“What is really nice is if a child might need a little bit longer term counseling, then they can settle in with that person,” said Jenny Lane, K-7 counselor and acting director of guidance at South Royalton School. And, she added, having the service available during the school day is ideal: Parents don’t have to transport students during the work day, and children can see a counselor during study halls.

Dental Health: ‘The Craters That We Would Look At’

The clinics’ original grant included dental care, and when they first started, it piloted a grant-funded dental health program that came to serve as the model for Vermont's Tooth Tutor Dental Access Program. The state provided extra grant money to hire nurse hygienist Merry Muller to provide school-based dental health education, fluoride rinses and visual screenings for decay. But when funding dried up, the clinicswere unable to provide those services.

The clinics’ dental program remained dormant for a time, but then, thanks in part to lobbying by Health Hub employees, state laws governing billing for dental services changed, Foulk said. Now, dental hygienists can provide and bill for some direct services such as X-rays, cleanings and molar sealants under the supervision of a dentist who is not required to be onsite.

Then Sen. Bernie Sanders, I-Vt., earmarked about $94,000 for them to start a dental program as it exists now, Foulk said. The grant helped them buy dental equipment and “basically outfit the trailer” in which Muller provides dental services.

The vehicle, essentially a mobile dental office, was purchased by Chelsea Health Center, part of Gifford Medical Center, as part of a collaborative effort to expand access to dental care. Itvisits the schools in the supervisory union, and several other Vermont schools, twice a year, staying for weeks at a time.

Recently, the shiny whitetrailer was parked outside South Royalton School. Inside, Muller joked with a seventh-grader who had come in for a cleaning. The boy, who’s known Muller for four years, smiled when she showed him a photograph on her laptop — him as an elementary school student.

“Are you ready?” she asked, and then offered a tooth-related reminder. Soda is “really, really bad.”

In an effort to establish good dental hygiene habits, Muller encourages parents to bring in their preschool-aged children. And she hopes the lessons she offers year after year will stick. Even if they don’t get regular care after they graduate, “maybe they’ve got it back here, as to what really happens,” she said, pointing to her head.

Students who need more work, such as fillings, are referred to dentists. If a family doesn’t have a dentist, clinic staff helps them find one. Some providers won’t take Vermont Medicaid, but “99 percent of the time, we can find (them) a dental home,” Gnaedinger said. “It’s not quite as good as we’d like, but it’s definitely better than it was.”

Having access to regular dental work and services such as fluoride supplements is “just incredible” for children’s overall health, Lamson said.

Vermonters have a history of poor dental health, he said. “Kids grow up to become adults with few or no teeth, which has an enormous impact on their health, what foods they can eat.”

Last year, Muller saw more than 400 students, many of whom were receiving dental services for the first time, Foulk said.

Clinic employees say they’ve seen a big difference in students’ dental health since the program started about four years ago.

“The craters that we would look at,” said Susan Hull, school nurse in Tunbridge and clinical coordinator for four of the Health Hub sites. “You don’t know how that kid is not screaming in pain.”

Why it Works, And What’s Next

Health Hub is funded through insurance payments, small grants and fundraising. Close to 70 percent of the patients receive insurance through Medicaid, and most of them are on Dr. Dynasaur.

“We are essentially self-sustaining, but certainly not profit-making,”Lamson said.

But in an era of unprecedented changes in health care, the nonprofit has managed to grow.

In a lot of ways, Health Hub has done exactly what they hoped it would, Foulk said. “Instead of doing it one on one, you can talk to a group of kids,” and Lamson spends time in the classrooms talking with students about nutrition, drugs and alcohol, and sexuality, and has even led classes on baby-sitting.

Also, the clinics have definitely improved immunization rates locally, she said. When the hepatitis B vaccine first became required in Vermont, they were able to hold clinics in the schools “and immunize a lot of kids all at once.”

She would love to see the model replicated in other supervisory unions, “but not necessarily by us,” Foulk said. “We are doing about what we can do.”

As it is, they already put in unpaid hours.

“The people who are involved really believe in the value of this effort,” and their donated time is what makes it work, she said. They make ends meet by “having a lot of people volunteer their time and effort,” and employees work unpaid hours to write grants and “kind of fill in the extras.”

Their goals for the future include “a modest expansion,” such as providing individual mental health counseling after school, so as not to interfere with classes, Lamson said. “We’re trying to do the best we can with the patients we have. … The reason we’re here is to listen to what they have to say and not to shuffle them out the door in 9 1/2 minutes.”

Lamson and his colleagues maintain their enthusiasm for the work, even as the years roll on.

“I feel it really does help to change people’s lives,” he said. Although sometimes, especially for troubled teens, that change can take years.

“They get used to people leaving them stranded,” Lamson said. But over time, positive interventions can make an impact.

“You have to stick around sometimes to see how they play out,” he said.

He recalled a student from a “somewhat abusive background” who came in for a pregnancy test that happily turned out to be negative. The girl, who hadn’t had access to health care, eventually had her teeth fixed, which boosted her self-esteem. She also worked with Lamson on safety issues and on an adolescent health project that focused on risky behaviors and decision-making. The student went on to college and later became a teacher.

“The important thing is just to be there. Who knows what’s the key?” he said. “If you’re there, maybe you’re part of it.”

Aimee Caruso can be reached at acaruso@vnews.com or 603-727-3210.

CORRECTION

When the South Royalton School-Based Health Clinic first opened, it piloted a grant-funded dental health program that came to serve as the model for Vermont's Tooth Tutor Dental Access Program. An earlier version of this article incorrectly described Tooth Tutor and the pilot project.